Updated: 5/18/2020

Genital Herpes in Pregnancy

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  • A 24-year-old G1P0 woman at 27 weeks gestation presents with painful lesions on her genitals. She denies any fevers, chills, or other flu-like symptoms. She reports that she has had ulcers in that area before that tested positive for HSV-2. She reports being concerned about transmission to her baby. She is started on acyclovir, which is a pregnancy category B medication.
  • Overview
    • untreated genital herpes (most commonly herpes simplex virus-2) in pregnancy results in an increased risk of neonatal herpes simplex virus (HSV) infection
    • in a primary HSV infection, the transmission rate to the neonate is 50%
  • Epidemiology
    • incidence
      • 5% of all women of childbearing age have a history of genital herpes
      • 22% of pregnant women are infected with HSV-2
    • demographics
      • pregnant women
    • risk factors
      • women
      • previous genital infection
      • number of sexual partners
  • Pathogenesis
    • mechanism
      • HSV is transmitted via direct contact with mucosa or disrupted skin
      • HSV transmission to the neonate occurs with passage of the neonate through the infected vaginal canal
  • History
    • history of genital ulcers
  • Symptoms
    • common symptoms
      • may be asymptomatic
      • genital ulcers
  • Physical exam           
    • inspection
      • tender erosions on external genitalia, vagina, or buttocks
  • Lesional studies
    • viral culture
    • polymerase chain reaction for HSV-1 and HSV-2
    • Tzanck smear
      • multinucleated epithelial giant cells
  • Varicella zoster virus infection
    • key distinguishing factor
      • rash is often more vesicular, with vesicles on an erythematous base that can become pustular
      • if reactivation of VZV, vesicles will group along a dermatome
  • Delivery
    • vaginal delivery
      • if there are no active lesions
    • cesarean delivery
      • if there are active lesions, cesarean delivery should be performed within 4-6 hours of membrane rupture
  • Medical
    • acyclovir and valacyclovir
      • indications
        • all patients with active recurrent or primary genital herpes
        • pregnancy category B
  • Erythema multiforme
  • Disseminated HSV infection
  • Neonatal transmission
  • Eczema herpeticum

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